Health inspection·January 3, 2025

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one of two sampled residents (Resident 1) to return to the facility after hospitalization. Resident 1 was discharged to a different nursing facility after their hospitalization. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization, violated Resident 1's rights to return to their facility, and resulted in Resident 1's displacement in an unfamiliar facility requiring adjusting to new surroundings. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 to the facility on 7/15/2024 and readmitted the resident on 10/29/2024 with diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 needed moderate assistance from staff with oral hygiene, toileting hygiene, bed mobility (movement) and transfer, and needed maximum assistance from staff with upper/lower body dressing and walk. During a review of Resident 1's physician's order dated 12/20/2024, the physician order indicated an order to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) for disturbance behavior manifested by hallucination (when you see, hear, smell, taste, or feel something that seems real but isn't actually there), combativeness, throwing himself onto the floor, and wandering (means to move around without a specific destination or purpose, like aimlessly walking from place to place without a plan). During a review of Resident 1's Progress Notes dated 12/20/2024 timed 10:30 p.m., the progress note indicated the facility transferred Resident 1 to GACH 1 via gurney service (transport patients who are unable to walk easily or need to lie flat) picked up by regular ambulance. During a review of Resident 1's Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave [absences for purposes other than required Page 1 of 3 555137 555137 01/03/2025 Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospitalizations] or hospitalization) Form, dated 12/23/2024, the Bed Hold Form indicated Resident 1 had a bed hold from 12/20/2024 to 12/26/2024. Resident 1's Bed Hold Form also indicated Family Member 1 had authorized an extended bed hold from 12/27/2024 to 1/2/2025. During a review of the facility's census (daily list indicating resident names with corresponding room numbers) dated 12/27/2024 to 1/2/2025, the facility's census indicated Resident 1's bed was on bed hold. During a review of Resident 1's Progress Notes dated 12/27/2024 timed 12:57 p.m., the progress note indicated that the Director of Nursing (DON) spoke with the case manager at GACH 1 regarding Resident 1's discharge plan, which was to return to the facility once psychiatrically (relating to mental illness) stable. The progress note indicated the DON discussed that per documentation reviewed (GACH 1 Inquiry #1), Resident 1 continued to be suspicious, labile (having rapid, unpredictable, or uncontrolled shifts in mood or emotions), and had flight of ideas (symptom of a mental health condition that involves rapidly shifting thoughts that are expressed through speech), and those behaviors still indicated that Resident 1 needed acute (sudden) psychiatric management at that time. The progress note indicated at that time (12/27/2024) the facility declined GACH 1's referral as the facility was not able to meet the resident needs. The progress note indicated the facility would accept Resident 1 once psychiatrically stable. During a review of GACH 1's Progress Notes dated 12/28/2024 timed 11:54 a.m., the documents indicated, Plan: Patient (Resident 1) was scheduled for discharge yesterday (12/27/2024) but the facility refused to accept him (Resident 1) saying that he (Resident 1) is still not stable did not tell me (Physician 1) what they (Facility) mean by that or where did you (Facility) find that because I (Physician 1) feel patient (Resident 1) is very stable and I (Physician 1) cleared him (Resident 1) for discharge. I (Physician 1) informed the social worker to talk to the family and talk to the state (State Survey Agency) and find out if we (GACH 1) can either enforce the patient (Resident 1) to go to his facility that he (Resident 1) wants to go back to or to find a different facility for him (Resident 1) for discharge as soon as possible. During a concurrent interview and record review on 1/3/2025 at 10:17 a.m., with the Director of Nursing (DON), reviewed Resident 1's Progress Notes written by the DON on 12/27/2024 timed 12:57 p.m. The DON stated when the DON reviewed GACH 1 Inquiry #1 received from GACH 1 on 12/26/2024, GACH 1 Inquiry #1 indicated that Resident 1's mood was still labile and indicated that Resident 1 needed acute psychiatric management at that time, so that the facility declined GACH 1's referral and decided to accept Resident 1 once Resident 1 was stabilized. The DON stated the facility received GACH 1 Inquiry #1 on 12/26/2024, GACH 1 Inquiry #2 on 12/27/2024, and GACH 1 Inquiry #3 on 12/30/2024. During a concurrent interview and record review on 1/3/2025 at 11:08 a.m., with the Administrator (ADM), reviewed GACH 1's Progress Notes dated 12/28/2024 timed 11:54 a.m., GACH 1 Inquiry #1 received on 12/26/2024, GACH 1 Inquiry #2 received on 12/27/2024, and GACH 1 Inquiry #3 received on 12/30/2024. The ADM stated that GACH 1's Progress Notes dated 12/28/2024 timed 11:54 a.m., indicated that GACH 1's physician (Physician 1) cleared Resident 1 to be discharged to the facility on [DATE], but ADM stated when the facility reviewed GACH 1 Inquiry #1, #2, and #3, the facility still believed Resident 1 was not stable enough to be discharged from GACH 1. The ADM stated a meeting was planned with Resident 1's family and GACH 1's social worker on that day, 1/3/2025, but the ADM found out that Resident 1 was discharged on that morning and left GACH 1 to Skilled Nursing Facility 1 (SNF 1, located 19 miles away from the facility), which was a locked facility (facility secured with locked doors preventing a resident from leaving at will). The ADM further stated that the facility was waiting for 555137 Page 2 of 3 555137 01/03/2025 Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335

F 0626 Level of Harm - Minimal harm or potential for actual harm Resident 1's behaviors to calm down and stabilize to come back to the facility. The ADM stated the facility did not try to refuse Resident 1's return to the facility, because the facility was Resident 1's home. The ADM stated a hospital therapeutic leave (absence from a nursing facility) was not part of the discharge plan so Resident 1 should return to the facility, but there was a miscommunication and Resident 1 ended up at SNF 1. The ADM stated the facility was going to contact SNF 1 and would bring back Resident 1 to the facility. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, readmission to the Facility, last reviewed on 10/2024, the P&P indicated, Resident/patients who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility regardless of payer source. 555137 Page 3 of 3